The extent to which interventions focused on appropriateness of urinary catheter placement reduce unnecessary urinary catheter use in the emergency department (ED) is not well understood. The long-term goal of this project is to identify and implement effective strategies to reduce inappropriate catheter use in the ED, thereby reducing overall catheter use and preventing catheter-associated urinary tract infection (CAUTI). The objectives of this proposal are to examine the effectiveness of collaborative efforts focused on reducing inappropriate catheter use in the ED and to identify key factors influencing this important CAUTI prevention strategy across multiple sites. Since the ED plays a key role in initial catheter placement, the main rationale for the proposed research is that ensuring the appropriate use of catheters and preventing CAUTI requires identifying and implementing ED-based interventions. This study has two specific aims: 1) To determine changes and compare differences in urinary catheter use and CAUTI rates following 2 distinct multi-site interventions (one state-based and one system-based) to reduce inappropriate urinary catheter insertion in the ED; and 2) To identify and compare the barriers to and facilitators of implementing interventions to reduce urinary catheter use across a diverse group of EDs. Secondary analyses using quantitative data from a total of 48 hospitals participating in 2 distinct collaborative ED interventions will be conducted in Aim 1. These data will include hospital characteristics, as well as process measure data on catheter use and appropriateness collected at baseline, implementation and sustainability time points of the interventions. A combination of site-specific CAUTI rate data and CAUTI- specific standardized infection ratio data will be used to assess outcomes. For Aim 2 we will use qualitative methods, consisting of both phone interviews and site visits. This approach will allow us to further examine the complex organizational factors that serve as either facilitators or barriers to reducing inappropriate catheter use in the ED. The expected outcomes of the proposed aims are multi-site quantitative estimates of changes in catheter use and CAUTI rates following ED interventions, as well as insights into key factors underlying the quantitative changes observed. The results will positively impact the fields of infection prevention and patient safety by providing novel insights and direction for establishing ED intervention efforts to reduce catheter use and CAUTI. The significant contribution to this area of research is expected to be an understanding of the effectiveness of collaborative ED interventions, an examination of the influence of implementing collaborative ED interventions under 2 distinct organizational frameworks (state- vs. system based), a delineation of the numerous aspects that facilitate or impede appropriate catheter use in typically busy ED environments, and an assessment of CAUTI rate changes following ED interventions. The proposed innovative, mixed-methods approach will yield valuable information that can be used to inform the development of interventions that can be tailored to the particular organizational context of EDs across the United States and shared with organizations motivated to intervene in the ED to reduce CAUTI.